1. ACLS Update and Review
Dwight Owen
Stephanie Tang
Leticia Varella

2. Case
 62 yo man with met CRPC with diffuse bone




metastases s/p multiple radiation treatments with
refractory pain
Admitted with back pain for r/o spinal cord
compression
Could not tolerate MRI  CT instead without
obvious compression
Given steroids with PPI, DVT ppx
Home methadone continued during admission for
pain control, lexapro for depression, albuterol prn
for SOB (former smoker, ? Mild COPD)

3. Morning Sign Out
 Overnight, patient again failed to tolerate MRI
despite pre-medication with ativan and
methadone PCA
 Was agitated and aggressive, but afebrile with
other VSS, haldol x 1 given in MRI suite

4. Morning Rounds
 When you round on the patient in the morning, he
is unresponsive.

5. Vitals
 HR 96
 BP 90/60
 RR 6
 S02 88%
 Afebrile
 BG: 60
 Pinpoint pupils, no wheezing, moving ext x 4
 Naloxone 0.4 mg x1 given without improvement

6. Lab from yesterday
 CBC: Hgb 8.9 (baseline)
 BMP: 140/4.2
 Phos 2.5
 Mg 1.1
106/33
29/1.4 < 71

8.  Biphasic unsynchronized shock (ie defibrillation)
delivered at 200J
 Next step?
 ROSC obtained during next rhythm check
 Still not following commands

9. BLS:
Because you don’t always have a code cart

10. BLS
 No more “look, listen, and feel.”
 Continued emphasis has been placed on high-
quality CPR
 chest compressions of adequate rate and depth
 allowing complete chest recoil after each
compression
 minimizing interruptions in compressions
 avoiding excessive ventilation

11. BLS
 There has been a change in the recommended
sequence for the lone rescuer to initiate chest
compressions before giving rescue breaths (C-A-B
rather than A-B-C). The lone rescuer should begin
CPR with 30 compressions rather than 2
ventilations to reduce delay to first compression.
 Compression rate should be at least 100/min
(rather than “approximately” 100/min).
 Compression depth for adults has been changed
from the range of 1 to 2 inches to at least 2 inches
(5 cm).

12. AED

13. AED
 Shock First vs CPR First
 1-Shock Protocol vs 3-Shock Sequence (no
stacking)
 Defibrillation Waveforms and Energy Levels
(Biphasic > Monophasic)
 Synchronized Cardioversion
 Afib: Biphasic 120-200J
 Aflutter Biphasic 100 J
 If first attempt fails, increase dose incrementally

14. Synchronized Cardioversion
 Unstable SVT
 Unstable atrial fibrillation
 Unstable atrial flutter
 Unstable monomorphic (regular) VT
 Synchronization avoids shock delivery during the
relative refractory period of the cardiac cycle
when a shock could produce VF

15. Synchronized vs Unsynchronized
 If there is any doubt whether monomorphic or
polymorphic VT is present in the unstable
patient, do not delay shock delivery to perform
detailed rhythm analysis: provide high-energy
unsynchronized shocks (ie, defibrillation doses).

16. Treatment?
With a pulse
Adult stable monomorphic VT responds well to
monophasic or biphasic waveform cardioversion (synchronized)
shocks at initial energies of 100 J. If there is no response to the
first shock, it may be reasonable to increase the dose in a stepwise
fashion.

17. Treatment?
Without a pulse
Pulseless arrest algorithm

18. Treatment?
SBP 150
SBP 70
Unstable polymorphic ventricular tachycardia is treated with
unsynchronized shocks (defibrillation). Defibrillation is used
because synchronization is not possible.

19. The wave of the future

20. With initiation of CPR, cardiac output is the major determinant of
CO2 delivery to the lungs
100% sensitivity and 100% specificity in identifying correct
endotracheal tube placement.

21. 40 mmHg
15 mmHg

26. High Quality CPR
 Maintain 30:2 ratio until advanced airway
 Minimize interruptions in CPR
 De-emphasis on Devices, Drugs, and Distractions
 Allow complete chest recoil after each
compression
 Rate of at least 100 compressions/min

27. Medications
 Atropine is no longer part of pulseless arrest
algorithm
 Central line ideal, however should not delay time
to CPR or meds
 IO if two failed attempts at IV
 ETT?

28. What medications can be absorbed
through the trachea?
 Lidocaine
 Epinephrine
 Atropine
 Naloxone
 Vasopressin

29. Post Cardiac-Arrest Care
 Hypothermia protocol
 Taper Fi02 to keep Sa02 > 94%
 Identify and treat ACS and other reversible
causes
 Anticipate, treat, and prevent multiple organ
dysfunction. This includes avoiding excessive
ventilation and hyperoxia.
 Transport/transfer to an appropriate hospital or
critical care unit with a comprehensive post–
cardiac arrest treatment system of care

31. Medications not generally
recommended during cardiac arrest
 Atropine
 Sodium Bicarbonate
 Calcium
 Fibrinolysis ?

32. Mega-code
 A 40 year old man arrives at the ER accompanied by his
family. He is complaining of palpitations after working
outside for several hours. The assessment is as follows:
 SKIN: pale, warm and dry
CVS: Strong peripheral pulses and a BP of 125/80
CNS: Fully intact
RESP: RR is 22, no resp. distress, lungs CTA
 An EKG is obtained

34. What is the next appropriate intervention?
A – Adenosine 6 mg IVP through closest line to the heart
followed by 20 ml NS push
B – Attempt vagal maneuvers
C – Perform synchronized cardioversion
D – Give epinephrine 1 mg IVP

35. What is the next appropriate intervention?
A – Adenosine 6 mg IVP through closest line to the heart
followed by 20 ml NS push
B – Attempt vagal maneuvers
C – Perform synchronized cardioversion
D – Give epinephrine 1 mg IVP
Lim SH et al. Comparison of treatment of supraventricular tachycardia by Valsalva
maneuver and carotid sinus massage. Ann Emerg Med 1998 Jan 31 30 35

36. You have performed vagal maneuvers and there is no
change in the patient’s heart rate and rhythm. What is your
next step?
 A - Give adenosine 6mg rapid IV push. If no
conversion, give 12mg rapid IV push
 B - Give adenosine 12mg rapid IV push. If no
conversion, give another 12mg rapid IV push
 C - Give Amiodarone 150mg over 10 minutes.
May repeat as needed
 D - Continue to attempt vagal manuvers until the
patient converts to a regular sinus rhythm

37. You have performed vagal maneuvers and there is no
change in the patients heart rate and rhythm. What is your
next step?
 A - Give adenosine 6mg rapid IV push. If no
conversion, give 12mg rapid IV push
 B - Give adenosine 12mg rapid IV push. If no
conversion, give another 12mg rapid IV push
 C - Give Amiodarone 150mg over 10 minutes.
May repeat as needed
 D - Continue to attempt vagal manuvers until the
patient converts to a regular sinus rhythm

38. You give 6mg Adenosine rapid IV push with no effect. 12mg
Adenosine rapid IV push is then given. The patient develops
severe ongoing chest pain and his vital signs are: HR
220, BP (not obtainable), and weak pulse. Your next step
should be.
 A – Immediate defibrillation
 B – Give 2nd dose of adenosine rapid IVP
 C – Perform immediate synchronized
cardioversion
 D – Perform precordial thump

39. You give 6mg Adenosine rapid IV push with no effect. 12mg
Adenosine rapid IV push is then given. The patient develops
severe ongoing chest pain and his vital signs are: HR
220, BP (not obtainable), and weak pulse. Your next step
should be.
 A – Immediate defibrillation
 B – Give 2nd dose of adenosine rapid IVP
 C – Perform immediate synchronized
cardioversion
 D – Perform precordial thump

40. Stable or Unstable SVT?
 Shortness of breath
 Palpitation feeling in chest
 Ongoing chest pain
 Dizziness
 Rapid breathing
 Loss of consciousness
 Numbness of body parts

41. Stable or Unstable SVT?
 Shortness of breath
 Palpitation feeling in chest
 Ongoing chest pain
 Dizziness
 Rapid breathing
 Loss of consciousness
 Numbness of body parts
Unstable patients with SVT and a pulse are always
treated with cardioversion

42. After synchronized cardioversion is unsuccessful, the pt.
continues to deteriorate. The patient is now unconscious. No
pulse is palpable. Below is what you see on the monitor:
What is your first intervention:
A – Deliver 2 minutes of CPR and then re-assess rhythm
B – Give epinephrine 1 mg IV push and repeat every 3-5 minutes
C – Give one unsynchronized shock (120-200 J)
D – Place an advanced airway

43. After synchronized cardioversion is unsuccessful, the pt.
continues to deteriorate. The patient is now unconscious. No
pulse is palpable. Below is what you see on the monitor:
What is your first intervention:
A – Deliver 2 minutes of CPR and then re-assess rhythm
B – Give epinephrine 1 mg IV push and repeat every 3-5 minutes
C – Give one unsynchronized shock (120-200 J)
D – Place an advanced airway

44. The patient does not respond to the defibrillation
with 120 J. He remains unconscious in ventricular
tachycardia. What is your next intervention?
 A – Deliver up to two additional shocks of 200 J
 B – Give 1 mg epinephrine IV push and repeat
q3-5 min
 C – Give
2 minutes of CPR
 D – Check the rhythm and the pulse

45. The patient does not respond to the defibrillation
with 120 J. He remains unconscious in ventricular
tachycardia. What is your next intervention?
 A – Deliver up to two additional shocks of 200 J
 B – Give 1 mg epinephrine IV push and repeat
q3-5 min
 C – Give
2 minutes of CPR
 D – Check the rhythm and the pulse

46. After completing 2 minutes of CPR, your rhythm check
indicates a second shock. You shock a second time with 160
J, and the patient's rhythm does not change. You resume
CPR. While completing the cycle of CPR what else should be
done?
 A – Epinephrine 1 mg IVP q3-5 min
 B – Vasopressin 40 mg IVP to replace first or
second dose of epinephrine
 C – Epinephrine 0.5 mg q3-5 min
 D – Both A and B

47. After completing 2 minutes of CPR, your rhythm check
indicates a second shock. You shock a second time with 160
J, and the patient's rhythm does not change. You resume
CPR. While completing the cycle of CPR what else should be
done?
 A – Epinephrine 1 mg IVP q3-5 min
 B – Vasopressin 40 mg IVP to replace first or
second dose of epinephrine
 C – Epinephrine 0.5 mg q3-5 min
 D – Both A and B

48. You have given the epinephrine or vasopressin and
completed the 5 cycles of CPR. A rhythm check reveals no
change. You attempt at third defibrillation. What will be your
defibrillator setting? (assume biphasic)
 A – 160 J
 B – 200 J
 C – 300 J
 D – 360 J

49. You have given the epinephrine or vasopressin and
completed the 5 cycles of CPR. A rhythm check reveals no
change. You attempt at third defibrillation. What will be your
defibrillator setting? (assume biphasic)
 A – 160 J
 B – 200 J
 C – 300 J
 D – 360 J

50. The third shock does not change the rhythm and you restart
CPR. You have shocked, you have given vasopressors
(epinephrine and/or vasopressin), you have continued with
effective CPR. What medication should be considered at this
point?
 A – Atropine
 B – Adenosine
 C – Amiodarone
 D – Amiloride

51. The third shock does not change the rhythm and you restart
CPR. You have shocked, you have given vasopressors
(epinephrine and/or vasopressin), you have continued with
effective CPR. What medication should be considered at this
point?
 A – Atropine
 B – Adenosine
 C – Amiodarone
 D – Amiloride

52. What is the correct dosing for amiodarone in the
Pulseless Arrest Algorithm?
 A – 150 mg IV once, if not effective may give one
additional dose of 300 mg IV
 B – 200 mg IV once
 C – 300 mg IV once, may be repeated with 150
mg IV one additional time
 D – Infusion of 300 mg IVPB in one hour

53. What is the correct dosing for amiodarone in the
Pulseless Arrest Algorithm?
 A – 150 mg IV once, if not effective may give one
additional dose of 300 mg IV
 B – 200 mg IV once
 C – 300 mg IV once, may be repeated with 150
mg IV one additional time
 D – Infusion of 300 mg IVPB in one hour

54. Amiodarone
 Ca Channels
 Na Channels
 K Channels
 Alpha-adrenergic
 Beta-Adrenergic
 Refractory VF/Pulseless VT

55. In addition to amiodarone, what other antiarrhythmic can you
consider as part of the pulseless arrest algorithm?
 A – Labetalol
 B – Lidocaine
 C – Digoxin
 D - Flecainide

56. In addition to amiodarone, what other anti-arrythmic can
you consider as part of the pulseless arrest algorithm?
 A – Labetalol
 B – Lidocaine
 C – Digoxin
 D - Flecainide

57. Great Job! You saved the patient He has been
stabilized and intubated, but does not respond to
verbal commands. He is transported to the hospital's
ICU. Since the patient is not responsive what would be
the most important intervention in the post-cardiac
arrest phase?
 A – Monitor waveform capnography
 B – Obtain ABG
 C – Induce therapeutic hypothermia
 D – Monitor oxygen saturation

58. Great Job! You saved the patient He has been
stabilized and intubated, but does not respond to
verbal commands. He is transported to the hospital's
ICU. Since the patient is not responsive what would be
the most important intervention in the post-cardiac
arrest phase?
 A – Monitor waveform capnography
 B – Obtain ABG
 C – Induce therapeutic hypothermia
 D – Monitor oxygen saturation

59. Possible Exclusion Criteria
 Coma from other cause besides cardiac
(toxins, CNS)
 Known bleeding diathesis / ongoing bleeding +/-
recent surgery
 Sepsis
 Ongoing shock with SBP < 90